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JAAOS2018 Flashcards

1
Q

Radiation dose relationship to proximity?

A

<div>radiation exposure DECREASES proportional to square of distance from source to surgeon (ie, small increases in distance = exponential decreases in radiation exposure)</div>

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2
Q

Types of radiation exposure effects?

A

Effects of Radiation<div><div>Exposure Deterministic</div><div>Effects Health consequences that occur after certain threshold of photons absorbed (eg, cataracts, hair loss, infertility)</div><div><br></br></div><div>Stochastic effects</div><div>Health consequences that occur randomly (each additional photon absorbed increases risk, but no threshold exists.) Mostly applied to health consequences as a result of DNA damage Eg, Cancer<br></br></div></div>

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3
Q

Most susceptible tissue to cancer induction from radiation? (higher number more sensitive)

A

“<img></img>”

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4
Q

Yearly radiation dose limit?

A

<div>20mSv/ year (ICRP), or 50mSv/year (NCRP). ICRP is international, and is the lower limit, so safer to use this one</div>

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5
Q

<div>1 Sv of cumulative radiation exposure =</div>

A

1 Sv of cumulative radiation exposure =<div>60% increase in risk of developing solid cancer</div><div>5% increase absolute risk of mortality from cancer</div><div>so, if exposure limit set at 20mSv/year, 50 years required before one is exposed to 1Sv, and getting the above mentioned risks</div><div><br></br></div><div>Cataract risk = same threshold risk for 20mSv/year</div><div><br></br></div><div>Offspring risk</div><div>Highest risk during 1st trimester (organogenesis)</div><div><br></br></div><div>Stochastic effect of increased fetal cancer risk RR of 1.4 for every 10mGy …but absolute risk of childhood cancer after 10mGy = 0.3%, and baseline absolute risk = 0.2%</div><div><br></br></div><div>ICRP still recommends prenatal radiation exposure limit of 0.5mSv/mo during pregnancy<br></br></div>

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6
Q

Methods to decrease radiation exposure?

A

Lead apron 0.25-.5mm thick (blocks 90-95%)<div>Leaded glasses (reduces 90%) - eliminates risk of cataracts</div><div>C-position - stand on intensifier side (4-8x less)</div><div>- 1 m away (only get -.3% of dose)</div><div>- Other staff > 2m away<br></br><div><br></br></div></div>

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7
Q

Effects of Vit D on Skeletal Muscle?

A
  1. Enhanced myosin on actin -> more forceful contraction<div>2. Stronger UE/LE indices</div><div>3. Increased vertical ump</div><div>4. Lower incidence of stress fracture</div><div><br></br></div><div>JAAOS - Effects of Vitamin D on Skeletal Muscle and Athletic Performance</div><div><br></br></div>
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8
Q

Felix classification of periprostehtic tibial stress fractures?

A

“Based on location and I-IV and stability A/B, C = intrap<div><br></br></div><div><img></img><br></br></div>”

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9
Q

Indications for ALL reconstruction?

A
  • young<div>- active</div><div>- pathologic rotatory laxity and imaging suggesting ALL injury</div><div>- Revision ACL wthout other factors causing failure</div>
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10
Q

Factors to optimize fracture healing?

A

“<div> <div> <div><img></img></div> </div></div>”

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11
Q

4 known muscle/bone factors implicated in supporting inflammatory phase of bone healing?

A

ILGF-1<div>Myostatin</div><div>BMPs (1)</div><div>Osteonectin</div>

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12
Q

Inflammatory cascade of # hematoma?

A

Migration of PMN (hours)<div>Macrophages replace neutrophils</div><div>T lymphoctytes initiate adaptive immune response</div><div>Mast cells help in bone repair<br></br></div>

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13
Q

RF for poor bone heaing in DM?

A
  • peripheral neuropathy<div>- Operative time inc 15% risk for every 10 mins (past a set time..)</div><div>- HbA1C > 7</div>
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14
Q

Patient related risk factors for poor bone healing?

A
  • DM 1 and 2<div>- NSAIDs</div><div>- Recent MVC</div>
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15
Q

RF for distal femur non-union

A
  • obesity<div>- open</div><div>- infection</div><div>- stainless steel plate</div><div>(note - smoking, DM, steroids not on there)</div>
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16
Q

RF for revision surgery in tibial non-union?

A
  • open<div>- transverse</div><div>- # gap</div><div>(No smoking/DM or steroids)</div>
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17
Q

Contraindication to VAC?

A

CSF leak<div>Bleeding disrder</div><div>Allergic to dressing</div>

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18
Q

Mechanism of VAC?

A

Speeds up 2nd intent<div>Increase blood flow</div><div>Removes edema and exudate</div>

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19
Q

RF for high risk SS complications (i.e. Consider a VAC)

A

DM, ASA >3, obesity smoker, hypoalbumin, steroids, high tension, revision

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20
Q

Contraindications to DFVO?

A

Absolute<div>Extreme valgus with tibial subluxation</div><div>Gross knee instability</div><div>Tricompartmental OA</div><div><br></br></div><div>Note: medial OA is absolute contra-indication, whereas moderate PF OA can be addressed with VDRO (although severe PF OA should be tx with arthroplasty) (medial OA)</div><div>Flexion contracture >15 deg</div><div><br></br></div><div>Relative Patient:</div><div>high BMI, RA, age>65 Knee: severe PF OA, severe lat comp bone loss, hx of SA<br></br></div>

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21
Q

Transfibular approach in TAA?JAAOS

A

Preserves deltoid ligament. Sacrificed ant talofibular… keeps skin blood supply, less bone loss

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22
Q

1st time dislocator OA?

A

> 50% develop some evidence of OA regardless of treatment.<div>ALso directly related to #d/l, cartilaginous trauma and timing or stabilization</div>

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23
Q

MPFL Origin and Insertion?

A

DA to Add tubercle (distal anterior)<div>Prox 1/2 of patella and quads tendon</div><div>Isometric</div>

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24
Q

Pathognomonic findings of patellar instability?

A

“Spur, double contour, crossing sign<div>Must have true lateral.</div><div><div> <div> <div><img></img></div> </div></div></div>”

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25
Q

Indications for trochleoplasty?

A

Dejour B/D, Spur > 5mm<div>Still need TTO and MPFL.</div><div>Contra - PF OA, open physis</div>

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26
Q

TTO Indications?

A

TTTG> 2 cm on CT, increased TT-PCL, Alta >1.2 CDS<div>Relative- lateral PF lesion</div><div>Coal is TTTG 10 mm</div>

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27
Q

Dejour Classification?

A

“<img></img>”

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28
Q

How much bone graft from RIA?

A

25-90 cc

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29
Q

How long till RIA regenerates?

A

14 months can reharvest.

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30
Q

Schottle point?

A

“True lateral<div>Posterior femoral cortex line, perpendicular lines at the start of the posterior curve and then most posterior point of bluemensaat. Go in this and anterior to blue.</div><div><img></img><br></br></div>”

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31
Q

Most common site of megaporthesis failure?

A

Proximal tibia

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32
Q

Main issues with megaprosthesis?

A

Infection<div>Soft tissue attachments</div>

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33
Q

Causes of GH chondral defects?

A

instability, iatrogenic chondrolysis, focal AVN, septic arthritis, RCTs, OCD

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34
Q

Iatrogenic causes of GH chondral defects?

A

local infusion<div>non-absorbale sutures</div><div>thermal devices</div><div>direct trauma</div><div>rate is 13%</div>

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35
Q

Ratcliff focal AVN of femoral head?

A

“1. XR sclerosis and Collapse<div>2. Neck AVN from fracture to the physis</div><div>3. Focla sclerosis of superolateral head</div><div><br></br></div><div><br></br></div><div><img></img><br></br></div>”

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36
Q

Acceptable reduction in peds femoral neck fractures?

A

Reduces non/malunion<div>Delbet</div><div>2 - <5 deg and < 2 mm trans</div><div>3 - < 10 deg</div>

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37
Q

Operative indications for tibial plateau?

A

<div> <div> <div> <div>Relative indications for surgery are an articular step-off of .3 mm, condylar widening of .5 mm, and 5 deg of coronal alignment disruption</div> </div> </div></div>

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38
Q

RF for non-union in tib plateau fractures?

A

Schatker 5, comminution, unstable fixtion, failure of implant

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39
Q

Prevention of UCL injuries?

A

“no pitching at least 4/12, limit counts and have rest days, single team/no overlapping seasons, don’t play pitcher anc catcher, play other sports, stop when it hurts.”

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40
Q

Reasons for poor sacral fixation?

A

cancellous bone, short capacious S1 pedicles, increase sacral slope = inc shear, fixation is anterior to the L5-S1 pivot point

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41
Q

Indications for spinopelvic fixation?

A

long contruct, high grade spondy, unstable sacral #, neuromuscular kid with deforming/obliquity

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42
Q

Triangular osteosynthesis?

A

“Skips sacrum - fixation from lumbar pedicle to the ilium. For vertical shear sacral fracture when you can’t get good Sacral fixation.”

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43
Q

MSTS Staging - most relevant for bone sarcoma

A

grade, site (intra/extracompartmental), mets

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44
Q

AJCC staging? Based on evidence

A

size (8 cm), grade (differentiation), LN, Mets.

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45
Q

STS where you want CT C/A/P?

A

Myxoid liposarcoma, epitheliod, leiomyosarcoma, angiosarcoma (LAME)

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46
Q

RF for VTE in c-spine sugery?

A

Posterior<div>Male</div><div>Teaching hopsital</div><div>Pulmonary or circulatory disease</div><div>Electrolyte abn</div>

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47
Q

RF for VTE in elective spine OR?

A

Corpectomy, BMI>40, paraplegia, ASA>4, LOs>7, SCI, medical comorbid

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48
Q

“Pathology of hip instability in Down’s?”

A

delayed walking, hypotonia, laxity

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49
Q

“Bony deformity in Down’s hip?”

A

Coxa valga, anteversion, acetabular dysplasia, acetabular retroversion (posterior uncoverage. UNSTABLE in flexion, adduction and internal

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50
Q

“Treatment of hip instability in Down’s?”

A

VDRO if <7<div>Pelvic osteotomy adolescents</div><div>- PAO or triple for posterior coverage preferrred.</div>

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51
Q

Female athletic triad?

A

New def - low energy, mentrual dysfunction, low BMD

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52
Q

Relative energy deficiency in sports: (can apply to males too)

A

impaired bone health and energy from malnutrition and endocrine abnormalities. INcreased risk for stress fractures.

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53
Q

ACL risk factors in female? (not necessarily causal)

A

narrow notch, increased tibial slope, est on laxity, landing mechanics

54
Q

Concussions worse in whic sex?

A

Females - higher incidence and severity and deficits.

55
Q

In dual mobility, which articulation move first?

A

Larger articulation only moves when smaller one maxes out and impinges between neck and insert.

56
Q

Definition of jumping distance?

A

<div> <div> <div> <div>the degree of lateral translation of the center of the fem- oral head that is needed for disloca- tion to occur</div> </div> </div></div>

57
Q

Retentive failure?

A

Loss of retaining power of poly liner rim holding small head in place. Only seen in dual mobility.

58
Q

RF for concussion?

A

previous concussion, high risk sport, female, 9-22 yrs, contact positions, loss of conciousness

59
Q

4 categories of concussive syptoms?

A

somatic, cognitive, emotional, sleep

60
Q

CTE symptoms:

A

behavioral, impulsivity, depression

61
Q

Season and Career ending injuries in concussion:

A

Season: > 2, dec academic/atheltic performance, abnormal MRI/CT<div>Career: decreasing energy of injury, ICH, prolonged post concussive symptoms, MR abnormalities (Chiari)</div>

62
Q

Concussion RTP protocol:

A

“<div> <div> <div><img></img></div> </div></div>”

63
Q

Maddocks questions?

A

At what venue are we today?<br></br>Which half is it now?<br></br>Who scored last in this match?<br></br>What did you play last week?<br></br>Did your team win the last game?

64
Q

Laterla extrusion in perthes?

A

epiphyseal width to amount of head extruded, >20 poor prognosis

65
Q

Characteristic deformity in basal thumb arthritis?

A

adducted with MCP hyperextension.

66
Q

Roberts view for basal thumb arthritis

A

“hyperpronation.<div><img></img><br></br></div>”

67
Q

Requirements for a biceps to triceps transfer for elbow extension?

A

Intact brachialis and supinator

68
Q

Definition of tetraplegia?

A

Cervical level SCI

69
Q

ICSHT

A

internationl classification for surgery of the hand in tetraplegia<div>- defines working uscles below the elbow starting at BR and going distal.</div>

70
Q

How to determine if both ECRB and ECRL are working?

A

5/5 power<div>Groove between muscle bellies - bean sign</div><div>ECRL only - radial deviates (2nd MC), 4/5 power</div>

71
Q

Candidats for TT in tetraplegia?

A

Functional goals, motivated, understands benefits and limitations, emotionally stable, adjusted to disability, commit to rehab.<div>C5-8 level injury, ICSHT 1 or better (need at least BR)</div>

72
Q

Candidate for functional electrical stimulation?

A

C5-6 level<div>No hand/wrist function with no surgical options</div><div>Can be driven by voice, resp, other movement. Best combined with TT.</div>

73
Q

3D PSI for hip arthroplasty?

A
  • better accuracy for cup<div>- no difference in duration of OR</div><div>- More expensive</div><div>- same complications</div><div>- outcomes TBD</div>
74
Q

Principles of early pilon fixation?

A

~12 hrs<div>- better reduction, similar fucntional outcome</div><div>- exclude in - hemmoragic blisters, contaminated, never between 3-5 days, EtOH, schizo, DM</div><div>- done by traumatologist</div>

75
Q

Angiosomes of the ankle?

A
  1. Anterior tibial<div>2. Posterior tibial</div><div>3. Peroneal</div>
76
Q

Techniques to reduce soft tissue issues in pilon #?

A
  • early OR<div>- Staged OR</div><div>- upgrading</div><div>- Partial fixation/sequential</div><div>- Fusion</div><div>- shortening</div><div>- transyndesmotic fixation</div><div>- MIS plating</div><div>- ring fixator</div>
77
Q

Factors associated with instability in RTSA

A
  • subscap def<div>- BMI >30</div><div>- Males</div><div>- revision</div><div>- deltopec approach</div><div>- bone loss</div><div>- trauma RTSA</div><div>- acromial #</div><div>- infection</div>
78
Q

Lateralized RTSA

A
  • increased stability<div>- tensions deltoid</div><div>- acromial stress #</div><div>- ?early glenoid failure</div><div><br></br></div>
79
Q

MIS vs. Open SI fusion?

A
  • less blood loss<div>- dec LOS</div><div>- dec OR time</div><div>- less post op pain</div><div>- complications same</div><div>- outcomes similar</div>
80
Q

Implicated factors in rapid post arhtroscopic chondrolysis?

A
  • indolent infection<div>- mechanical damage</div><div>- anchors?</div><div>- thermal injury</div><div>- chemical injury - local pump</div>
81
Q

How many bugs does it take to cause SSI with implant present?

A

10, 1000-100000 without.

82
Q

Typical deformity in distal femur fracture?<div>Spot for blocking screws?</div><div>Sept 2018</div>

A

Extension and valgus (occasionally varus)<div>Anterior and Lateral</div>

83
Q

Proximal tibia fracture deformity?<div>Blocking screw locations?</div><div>Sept 2018</div>

A

Valgus, procurvatum.<div>Blocking screws posterior and lateral</div>

84
Q

Judging proper AP for start point in tibial nail?

A

“Lateral plateau should bisect middle of proximal fibula<div><img></img><br></br></div><div><br></br></div>”

85
Q

Rate of PF damage in suprapatellar nailing?

A

30% in repeat scope.

86
Q

Safe zome for tibial nail start point?

A

“9 mm lateral to midline, 3 mm lateral to TT<div><img></img><br></br></div>”

87
Q

“Treatment for patellar instability you CAN’T do in open physis?”

A

TTO, Trochleoplasty

88
Q

Indications for lateral release in patellar instability?

A

TTTG>20<div>Lateral tilt</div><div>Fixed dislocations</div>

89
Q

Options for MPFL reconstruction in skelettaly immature?

A

MPFL - R<div>Guided growth</div><div>Hamstring sling (around MCL or Adductor magnus)</div><div>Patellar tendon slip</div><div>Realingment</div><div>- Roux Goldwaith</div><div>- Nietosvaara - semi-T out and aorund into schottle</div>

90
Q

What are the 3 kinematic axis of the normal knee?

A

Flexion axis of tibia<div>Flexion axis of patella</div><div>Longitudinal rotational axis - IR/ER</div>

91
Q

Distance from ACJ of CC ligaments?

A

Trapezoid - 2.5 cm<div>Conoid - 3.5 cm (20% length of clavicle)</div>

92
Q

RF for recurrence of lateral ankle instability?

A
  • global laxity<div>- high demand</div><div>- hindfoot cavovarus</div><div>- non-anatomic recon</div>
93
Q

Most common nerve injured in scopic lateral lig repair of the ankle?<div>Safe zone?</div>

A

Communicating branch of sural and SPN - 4.7 cm lat to lat mal (safe zone 1.5 cm)

94
Q

Start point for perc pedicle screw?<div>Wire?</div><div>Trajectory?</div>

A
  • center of lat pedicle on PA<div>- stay in lat 2/3 (dec medial wall penetration)</div><div>- just enter body on lat</div><div>- then use guide wire<br></br><div><br></br></div></div>
95
Q

Blocks to rod placement in PPSI?

A
  • muscle fascia<div>- bone (TP in T spine)</div><div>- uneven screw head alignment</div><div>- poor rod contour</div><div>- adjacent facet</div><div>- TL junction change in kyphosis</div>
96
Q

Reduction phases in rod insertion during spine surgery?

A
  • indirect, pt position<div>- manipulation of endplate</div><div>- distraction through rod</div>
97
Q

Factors affecting local inflammation?

A
  • soft tissue injury<div>- fracture hematoma</div><div>- stability</div><div><br></br></div>
98
Q

Systemic factors affecting inflammation?

A

Acute disease - polytrauma, sepsis<div>Chronic disease</div><div>Drugs - anti-inflam</div>

99
Q

4 muscle bone factors implicated in inflammatory phase of fracture healing?

A
  • ILGF - 1, early myokine<div>- myostatin</div><div>- BMPs</div><div>- Osteonectin</div><div><br></br></div>
100
Q

Risk factors for bone healing in DM?

A
  • neuropathy,<div>- length of OR, additional 10 mins risk 15% healing…</div><div>HbA1C> 7</div>
101
Q

RF for non-union of DFF?

A

obesity<div>open</div><div>infection</div><div>stainless steel plate</div>

102
Q

RF for revision in tibial non-union

A
  • open<div>- transverse</div><div>- fracture gap</div>
103
Q

Shoulder hyperlaxity? Anterior and Inferior?

A

> 85 deg ER in add<div>> 105 deg hyper abduct</div>

104
Q

Pathology associated with GH chondral defects?

A

instability, iatrogenic chondrolysis, focal ON, septic arthritis, RCT

105
Q

ASMI pitching guidelines?

A
  • 4/12 no pitching!<div>- pitch counts and rest days</div><div>- single team</div><div>- no pitcher catcher combos</div><div>- play other sports</div><div>- rest when pain</div>
106
Q

MSTS staging for bone sarcoma?

A

“<div> <div> <div><img></img></div> </div></div>”

107
Q

AJCC for bone sarcoma?

A

“<div> <div> <div><img></img></div> </div></div>”

108
Q

AJCC for STS?

A

“<div> <div> <div><img></img></div> </div></div>”

109
Q

RF for VTE in spine surgery?

A

Risk factors for VTE:<div>Posterior fusion (highest risk)</div><div>Male</div><div>Teaching hospital</div><div>Pulmonary/circulation pathology</div><div>Electrolyte abnormalities<br></br></div><div>Corpectomy</div><div>obesity</div><div>>ASA</div><div>> LOS</div><div>Paraplegia</div>

110
Q

Contributors to hip instability in DS?

A

<div>Soft tissue</div>

  • lig laxity<div>- capsula insufficiency</div><div>- hypotonia</div><div>Boney</div><div>- coxa valga</div><div>- anteversion neck</div><div>- dysplasia</div><div>- retroversion cup</div>
111
Q

Location of CAM? Position of impingement?

A

Anterosuperior neck, FADIR

112
Q

Best XR view for CAM?

A

“Modified Dunn<div><img></img><br></br></div>”

113
Q

Definition of CAM/overcoverage?

A

CEA or LCEA of >40

114
Q

Hip injection anterior?

A

2-3 cm below asis and 3 cm lateral to femoral artery

115
Q

Complications of joint aspiration and injection

A

“<img></img>”

116
Q

Age related changes in the ACL?

A

“<img></img>”

117
Q

Normal 4-5 IMA, 5th MTP angle?

A

IMA - 6.5<div>MTPA <13</div>

118
Q

Factors affecting loosening in medial UKA?

A

-metal backed > mobile<div>- 2 > 1 peg</div><div>- malalignment</div><div>- lowering med joint > 2mm relative to lat</div><div>- poor femoral fixation</div><div>- varus inclination tibia > 4 deg</div><div>- anteriorly angled fem cut</div><div><br></br></div>

119
Q

Most important preditor of lateral compartment progression in med UKA?

A
  • lat OA grade at time of UKA
120
Q

Benefits of hemi?

A
  • less OR time<div>- less blood loss</div><div>- more stable</div><div>- fewer post op comlications</div>
121
Q

Benefits of THA in fracture?

A
  • better pain relief<div>- lower long term re-op</div><div><br></br></div>
122
Q

1 year mortality in hip fracture?<div>Directly related to?</div>

A

30-40%, related to time to OR. <48 hrs dec mortality but even 24 –> 12 is better for 30 day mortality

123
Q

Amount of abx in 40g bag of cement? (definitive fixation)

A

> 4.5g decreases strength<div><2g/40g is standard</div><div>In staged revision 3.4 - 8.6 g, 8 grams changes workability</div>

124
Q

CAM - complete arthroscopic management indications for GH OA?

A
  • <50<div>- active</div><div>- symptomatic OA</div><div>- retained joint space</div>
125
Q

Contraindications to CAM for GHOA?

A

“<img></img>”

126
Q

Compesnatory plantar flexors?

A

PL, PB, FHL, FDL (these 4 may mask injury by being intact.<div>TP</div>

127
Q

Advantages of FHL TT in achilles over PB/FDL?

A
  • stronger<div>- same line of pull</div><div>- in-phase</div><div>- close to achilles</div><div>- brings in vascularity</div>
128
Q

Rate of contralateral fem neck/shaft fracture?

A

9%

129
Q

Indications for biopsy in lipomatous mass?

A

Heterogenous signal intensity<div>Lack isointense signal compared to fat</div><div>Post-contrast enhancement with Gad Necrotic areas<br></br></div>

130
Q

MRI findings of ATL?

A

+ Deep to Fascia<div>+ Larger than lipoma >10 cm</div><div>+ Thicker fibrous septae >2 mm</div><div>+ Post-Contrast Gad enhancement<br></br></div>

131
Q

4 ossification centers in os acromiale?

A

A –> P<div>pre, meso, meta, basi</div>

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